Valleyhead, Inc. Intensive Residential Program PRIVATE SPECIAL EDUCATION SCHOOL PROGRAM REVIEW DRAFT REPORT OF FINDINGS Dates of Onsite Visit: July 9 – 13, 2007 Date of Draft Report: September 25, 2007 Due Date for Comments: October 23, 2007 Date of Final Report: December 21, 2007 Action Plan Due: February 11, 2008 Department of Education Onsite Team Members: Sandra K. Hanig, Chairperson Betsy Holcombe Jeffrey Nellhaus, Acting Commissioner of Education MASSACHUSETTS DEPARTMENT OF EDUCATION PRIVATE SPECIAL EDUCATION SCHOOL PROGRAM REVIEW Valleyhead Intensive Care Program Table of Contents OVERVIEW OF REVIEW PROCEDURES 3 PRIVATE SCHOOL PROGRAM REVIEW ELEMENTS 3 DEFINITION OF TERMS FOR FINDINGS 8 AREA 1: REQUIRED INFORMATION, NOTIFICATIONS AND POSTINGS 9 AREA 2: ADMINISTRATION -- LEGAL AND FINANCIAL DOCUMENTATION 9 AREA 3: ADMINISTRATION -- MANUALS AND HANDBOOKS 12 AREA 4: DISCLOSURE OF INFORMATION 15 AREA 5: ADMISSIONS PROCEDURES AND COORDINATION/COLLABORATION WITH SCHOOL DISTRICTS 18 AREA 6: EDUCATIONAL PROGRAM REQUIREMENTS -- STUDENT LEARNING TIME 21 AREA 7: EDUCATIONAL PROGRAM REQUIREMENTS -- CURRICULUM FRAMEWORKS AND STATE ASSESSMENTS 24 AREA 8: EDUCATIONAL PROGRAM REQUIREMENTS -- INDIVIDUALIZED EDUCATION PROGRAMS 26 AREA 9: EDUCATIONAL PROGRAM REQUIREMENTS -- STUDENT DISCIPLINE AND BEHAVIOR MANAGEMENT 32 AREA 10: EDUCATIONAL STAFFING REQUIREMENTS -- STUDENT:TEACHER AND STUDENT:CHILDCARE WORKER RATIOS 36 AREA 11: EDUCATIONAL STAFFING REQUIREMENTS -- PERSONNEL POLICIES, QUALIFICATIONS, RESPONSIBILITIES 39 AREA 12: EDUCATIONAL STAFFING REQUIREMENTS -- STAFF TRAINING 46 AREA 13: PHYSICAL FACILITY AND EQUIPMENT REQUIREMENTS 52 AREA 14: REQUIREMENTS FOR DAILY CARE 57 AREA 15: PARENT AND STUDENT INVOLVEMENT 59 AREA 16: HEALTH AND MEDICAL SERVICES 63 AREA 17: TRANSPORTATION SAFETY 70 AREA 18: STUDENT RECORDS 70 Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 2 of 73 MASSACHUSETTS DEPARTMENT OF EDUCATION APPROVED PRIVATE SCHOOL PROGRAM REVIEW REPORT OVERVIEW OF REVIEW PROCEDURES INTRODUCTION The Massachusetts Department of Education is required under M.G.L. c. 71B, §10 to review special education programs in approved private special education schools that serve publicly funded students under the provisions of Board of Education Regulations 603 CMR 28.00 and 18.00. Each private school submits an application for approval by the Department of Education and periodically updates information included in the application on how special education services are provided. Each year, the Department's Program Quality Assurance Services unit conducts onsite visits to selected approved private schools to verify the implementation of their applications. The selected schools for 2006-2007 review cycle were notified in October 2006 of scheduled visits and were encouraged to assess themselves before the arrival of the Department's visiting team. The statewide six-year Private School Program Review cycle together with the Department’s Mid-cycle follow-up monitoring schedule is posted on the Department’s web site at http://www.doe.mass.edu/pqa/review/psr/6yrcycle.html. Private School Program Review Elements Team: Depending upon the size of a private school and the number of programs to be reviewed, a team of two to three Department staff members conducts a Program Review over two to five days in the private school. In some instances, Massachusetts’ human service agency staff and a representative of the local school district may also participate on the visiting team. Scope: All approved private schools in the Commonwealth are monitored through the Department's Private School Program Review system on a six-year cycle with an additional mid-cycle followup visit. This six-year monitoring and follow-up cycle is coordinated with the Department's Approved Private School Application Renewal procedures. Content: The Program Review criteria encompass key elements drawn from 603 CMR 18.00 and 28.00 and the private school’s application for approval. The elements selected for the 2005-2006 reviews also include those required by the federal Office for Special Education Programs (OSEP) and revised requirements of the Individuals with Disabilities Education Act, 20 U.S.C. Section 1400 et seq. (IDEA-2004) as described in the Department's Special Education Advisories. Selected Program Review compliance criteria are aligned with the requirements and goals of the Massachusetts Education Reform Act of 1993, being intended to promote high standards and achievement for all students. Report: The Department's Program Review Report is based on a review of documentation regarding the operation of the school's programs, together with information gathered through the following Department program review methods: Interviews of administrative, clinical, instructional and support staff across all grade levels. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 3 of 73 Interviews of Parent Group representatives. Other interviews as requested by personnel from state and local agencies and members of the general public. Review of student records: A sample of student records is selected for detailed review by the Department of Education. Student records are examined first by the school’s staff and then verified by the onsite team using standard Department student record review procedures in order to make determinations regarding the implementation of procedural and programmatic requirements. Parents of students whose files were selected for the record review are provided an opportunity to be interviewed by telephone. Observation of classrooms and other facilities: Instructional classrooms and school facilities used in the delivery of programs and services are visited to determine general levels of compliance with program requirements. Response: A detailed report of findings describes determinations about the implementation status of each requirement (criterion) reviewed. Included in the findings are commendations for those criteria that have been implemented in an exceptional manner. Where criteria are identified as not fully implemented, the private school must propose corrective action to bring those areas into compliance with the controlling statutes or regulations. Under new federal Special Education State Performance Plan requirements pursuant to IDEA-2004, public and private schools serving disabled students must demonstrate effective resolution of noncompliance identified by the Department as soon as possible but in no case later than one year from the issuance of the Department’s Final Program Review Report. Private schools are encouraged to incorporate the corrective action into their program improvement planning, as well as their professional and paraprofessional staff development plans. The Department believes that the Private School Program Review process is a positive experience and that the Final Report is a helpful planning document for the continued development and improvement of programs and services in each approved private school. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 4 of 73 REPORT INTRODUCTION A two-member Massachusetts Department of Education team visited Valleyhead Residential School during the week of July 9, 2007 to evaluate the implementation of selected compliance criteria under the Massachusetts Board of Education Regulations 603 CMR 18.00 (Program and Safety Standards for Approved Public or Private Day and Residential Special Education School Programs) and 603 CMR 28.09 (Approval of Public or Private Day and Residential Special Education School Programs), M.G.L c. 71B (“Chapter 766”) and the federal Individuals with Disabilities Education Act, 20 U.S.C. Section 1400 et seq, as amended in 1997 (IDEA-97). The team appreciated the opportunity to interview staff and parents, to observe classroom facilities, and to review the program efforts underway in the school. The Department is submitting the following Private School Program Review Report containing findings made pursuant to this onsite visit. In preparing this report the team reviewed extensive documentation regarding the operation of the school's programs, together with information gathered by means of the following Department program review methods: • • • • • • • • • Interviews of seven administrative staff. Interviews of three clinical staff. Interviews of four teaching and educational support services staff. Interviews of seven childcare staff. Interview of one Parent Group representative. Interviews of two representatives of state and local agencies responsible for placement of students in the school. Student record review: A sample of thirteen Massachusetts student records was selected by the Department. Student records were first examined by the school’s staff and then verified by the onsite team using standard Department of Education student record review procedures to make determinations regarding the implementation of procedural and programmatic requirements. Personnel record review: A sample of seventeen personnel records was selected by the Department. Observation of classrooms and other facilities: All instructional classrooms and other school facilities used in the delivery of programs and services were visited to determine general levels of compliance with program requirements. The report includes findings organized under the 18 compliance areas listed in the table of contents. The findings explain the “ratings,” or determinations by the team about the implementation status of the compliance criteria reviewed within each of the 18 areas. The ratings indicate those criteria that were found by the team to be substantially “Implemented” or implemented in a “Commendable” manner. (Refer to the “Definition of Terms” section of the report.) Where criteria were found to be either "Partially Implemented" or "Not Implemented," the private school must propose to the Department corrective action to bring those areas into compliance with the controlling statute or regulation. In some instances the team may have found certain requirements to be fully “Implemented” but made a specific comment on the school’s implementation methods that also may require response from the private school. The private school is expected to incorporate the corrective action into any program improvement plans, including the school’s professional and paraprofessional staff development plan. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 5 of 73 Valleyhead Intensive Care Program SUMMARY OF COMPLIANCE CRITERIA INCLUDED IN THIS REPORT REQUIRING CORRECTIVE ACTION PLAN DEVELOPMENT in response to the following PROGRAM REVIEW REPORT FINDINGS PROGRAM AREA PARTIALLY IMPLEMENTED Area 1: Required Information, Notifications And Postings 1.2 Area 2: Administration -Legal And Financial Documentation 2.5 Area 3: Administration -Manuals And Handbooks 3.2 Area 4: Disclosure Of Information 4.4, 4.5 Area 5: Admissions Procedures And Coordination/Collaboration With School Districts 5.1, 5.2, 5.5 Area 6: Educational Program Requirements -- Student Learning Time 6.1, 6.1(a) Area 7: Educational Program Requirements -- Curriculum Frameworks And State Assessments 7.1, 7.3 Area 8: Educational Program Requirements – Individualized Education Programs 8.1, 8.2, 8.7, 8.8, 8.9, 8.10, 8.11 Area 9: Educational Program Requirements -- Student Discipline And Behavior Management 9.1, 9.4 Area 10: Educational Staffing Requirements -Student:Teacher And Student:Child-Care Worker Ratios 10.2 NOT IMPLEMENTED 6.2 8.6 Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 6 of 73 OTHER CRITERIA REQUIRING RESPONSE PROGRAM AREA PARTIALLY IMPLEMENTED NOT IMPLEMENTED Area 11: Educational Staffing Requirements -- Personnel Policies, Qualifications, Responsibilities 11.1, 11.2, 11.3, 11.4, 11.9, 11.11 11.5 Area 12: Educational Staffing Requirements -- Staff Training 12.2, 12.2(c), 12.2(d), 12,2(g), 12.2(h), 12.2(i) Area 13: Physical Facility And Equipment Requirements 13.4, 13.5, 13.6, 13.8 Area 14: Requirements For Daily Care 14.3 Area 15: Parent And Student Involvement 15.1, 15.5, 15.8 Area 16: Health And Medical Services 16.3, 16.4, 16.5, 16.6, 16.7 Area 17: Transportation Safety 17.1 Area 18: Student Records 18.2 OTHER CRITERIA REQUIRING RESPONSE 13.7 15.3 NOTE THAT ALL OTHER CRITERIA REVIEWED BY THE DEPARTMENT THAT ARE NOT MENTIONED ABOVE HAVE RECEIVED AN “IMPLEMENTED” OR “NOT APPLICABLE or NOT RATED” RATING. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 7 of 73 DEFINITION OF TERMS FOR THE RATING OF EACH COMPLIANCE CRITERION Commendable The criterion is implemented in an exemplary manner significantly beyond the requirements. Implemented The requirement or criterion is substantially met. Partially Implemented The requirement, in one or several important aspects, is not entirely met. Not Implemented The requirement is totally or substantially not met. Not Applicable or Not Rated The requirement does not apply to the private school. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 8 of 73 AREA 1: REQUIRED INFORMATION, NOTIFICATIONS AND POSTINGS CRITERION NUMBER Legal Standard 1.2 Program & Student Description Program Capacity 28.09(2)(b)(2,3,7) A narrative is provided that describes the program’s: a. Operational capacity b. Identified population of students to be served, including the current and/or projected enrollment maximum enrollment, ages of students and their educational and behavioral characteristics c. Philosophy, goals and objectives d. Mechanisms for delivery of services Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Comment: Documentation submitted as part of this review states that Valleyhead School has been approved for enrollment of 48 students. In September 2006, Valleyhead’s request for special circumstances to change maximum enrollment from 59 to 34 students was approved by the Department of Education. Interviews and observations indicate that although The Department of Education has granted one approval for Valleyhead School, upon admission, students are assigned to a residence and classes that are located either on the main campus or at a location 2 miles away, referred to as “The Farm.” The organizational structure of the two locations differs. For example, the Residential Director does not have oversight of the campus at the Farm. Students who live and attend classes at one location rarely interact with students at the other location and are not offered the same access to educational and recreational opportunities. AREA 2: ADMINISTRATION -- LEGAL AND FINANCIAL DOCUMENTATION CRITERION NUMBER Legal Standard 2.1 The program provides a description of its legal status including names of individuals Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 9 of 73 CRITERION NUMBER Legal Standard and principal parties with ownership, oversight, and key administrative responsibilities. Legal Status 28.09(2)(b)4 The program maintains complete documentation on ownership, governance, management, mission, and mechanisms for service delivery. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 2.2 Approvals, Licenses, Certificates of Inspection 28.09(2)(b)45 28.09(5) 28.09(6) 18.04(1) The program has current licenses, approvals, and certificates of inspection by state and local agencies for: a. Building occupancy;* b. Safety inspection in all buildings by the Department of Public Safety or local building inspector; c. Annual fire safety inspection by local fire department;* d. Lead paint inspection (if applicable);* [See 102 CMR 308(4)(b): All buildings, residential or otherwise, utilized by children younger than six or with a mental age younger than six shall be free of lead paint violations in accordance with 105 CMR 460.000 (Massachusetts Department of Public Health Prevention and Control of Lead Poisoning regulations).] e. Health safety;* f. Approval by local school committee (per M.G.L. c. 76, s. 1); g. Approval by EEC to operate a group care facility or a special education day care center (if applicable);* h. Asbestos inspection or date when building was constructed and statement from appropriate authority that building is asbestos free; i. PCB inspection or date when building was constructed and statement from appropriate authority that building and all light ballasts are free from PCB’s; j. Other inspections that may be required by local or state authorities; and k. (If applicable) a statement as to whether previous application was made for approval, and the action that was taken on it. *A program with a residential component may submit the most recent EEC license to fulfill those requirements marked with an asterisk (*). Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 10 of 73 No CRITERION NUMBER Legal Standard 2.3 EEC License (NA to Day Schools) The program has a current, full license from Department of Early Education and Care (EEC (per 102 CMR 3.00) to operate as a residential school. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard The private school program maintains good standing with state and federal tax authorities and provides notification of any outstanding tax liabilities. 2.4 Financial Solvency 28.09(2)(b)4 Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 2.5 Financial Management 28.09(2)(b)4 The private school program maintains accurate records of receipts and expenditures, consistent with the regulations of the Massachusetts Operational Services Division, together with a Program Budget and a list of the proposed tuition rates for all publicly and privately funded students attending the school, including students from outside Massachusetts [808 CMR 1.00]. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 11 of 73 No AREA 3: ADMINISTRATION -- MANUALS AND HANDBOOKS CRITERION NUMBER Legal Standard All approved public and private special education schools shall maintain onsite a policies and procedures manual and shall provide written notice to parents of enrolled students that copies of such policies and procedures are available upon request. 3.1 Policies & Procedures Manual 28.09(11)(b) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 3.1(a) Contents The program’s manual must contain policies and procedures in all subject areas listed in the appendix at the back of this application. These policies and procedures include, but are not limited to: a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. u. v. Advanced notice of proposed program/facility change Student admissions Child abuse/neglect Discipline policies and procedures Suspension and termination Student discipline and behavior management Physical restraint Student runaway Notification of serious incidents (Form 2) Coordination and collaboration with school districts IEP- revisions and changes IEP- transition planning IEP- transition services State and district-wide assessments Progress reports Least restrictive placements Evacuation and emergency procedures Parent involvement Orientation for new parents and students Change of student’s legal status Obtaining parental consent Student involvement Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 12 of 73 CRITERION NUMBER Legal Standard w. x. y. z. aa. bb. cc. Registering complaints- parents and students Student protections Supervision of students Student records New staff orientation and annual in-service training Student transportation and transportation safety Research, experimentation, fund raising, publicity, and observation Appendix with all signed and dated Assurances sent to the Department in connection with this application. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 3.1(b) Private School Employment Practices Title VI: 42 U.S.C. 2000d; 34 CFR 100.3(c); EEOA: 20 U.S.C. 1703(d); Title IX: 20 U.S.C. 1681; 34 CFR 106.51-106.61; Section 504: 29 U.S.C. 794; 34 CFR 104.11-104.14; Title II: 42 U.S.C. 12132; 28 CFR 35.140; Mass. Const. amend. art 114 Employment practices in private special education programs in general are free from discrimination on the basis of race, color, national origin, sex or disability. In particular, faculty salary scales are based on the conditions and responsibilities of employment without regard to race, color, national origin, sex or disability, and employee recruitment is aimed at reaching all groups, including members of linguistic, ethnic, and racial minorities, females and males, and persons with disabilities. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 13 of 73 No CRITERION NUMBER Legal Standard The program maintains a written and current health care policies and procedures manual containing all required health-related policies and procedures as described in 603 CMR 28.00 and 603 CMR 18.00, and approved by a licensed physician. The manual is readily available to all staff and includes policies and procedures on the following subjects: a. Provision of medical, nursing, and infirmary care b. Emergency first aid (see criterion 16.4) c. Administration of medications, per DPH regulations d. Administration of anti-psychotic medications including, where appropriate, “Rogers Procedures” e. Students with Comfort Care/Do Not Resuscitate Orders (DPH Guidelines issued on November 30, 2004) f. Meningococcal Disease and Vaccination for Residential Schools with Grades 9-12 and Postsecondary Institutions that Provide or License Housing (Massachusetts General Laws, Chapter 76, s.15D and related regulations of DPH, 105 CMR 220.700) g. Preventive health care (see 16.7) h. Receipt of medical treatment in accordance with students’ religious beliefs i. No smoking policy (see Assurance on this subject) j. Toileting procedures k. Food and nutrition (see 14.2) l. Name and contact information for consultant physician and additional emergency contacts. 3.2 Health Care Manual 18.05 (9)(d) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates the health care manual for Valleyhead School does not include a policy on smoking. CRITERION NUMBER Legal Standard 3.3 Special Education Regulations and Reference Materials State regulations and specified excerpts from current federal special education regulations and related reference materials must be compiled and readily available for parents and staff to inspect. This compilation of materials must contain at least the following 5 documents: a. Current federal IDEA regulations: 34 CFR 300.300-.577 b. Appendix A to the above federal regulations Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 14 of 73 CRITERION NUMBER Legal Standard c. d. e. State: 603 CMR 28.00 Federal: 34 CFR 300.300-.577 and Appendix A State regulations: 603 CMR 28.00 and 603 CMR 18.00 The current Department of Education IEP Process Guide and IEP Forms State restraint regulations (for day schools) Rating: Implemented RESPONSE REQUIRED: No AREA 4: DISCLOSURE OF INFORMATION CRITERION NUMBER Legal Standard The private special education school shall make available to the Department information on all aspects of the school’s program(s), the license and/or credentials of its staff and the individual records of enrolled Massachusetts students. 4.1 Aspects of program, staff credentials and student records 28.09 (5)(a) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 4.2 The private special education school maintains on site and makes available for public Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 15 of 73 CRITERION NUMBER Legal Standard Public information and Postings 28.09(6)(a,b,c ,d,e), 28.09(2)(b)(4) review by posting in public locations the following: a. Documentation of the current approval or intake status issued by the Department of Education and/or licensing status issued by the Department of Early Care and Education (must be posted in a public location) b. First aid, medical and emergency procedures, location of nearest telephones within each building, and emergency telephone numbers (must be posted in each building) c. Evacuation routes and procedures (must be posted in each room) d. For public programs: a notice that use of tobacco products is not permitted on school property or at any school related function (must be posted in a public location) e. For private programs: a notice that use of tobacco products is not permitted in school buildings (must be posted in a public location) f. Program information including a statement of purpose, general description of educational program and an organizational chart In addition to the above, private special education schools must maintain the following information for public review: a. Current tuition rate for students b. Evidence of authority to operate the private school including Documents that identify ownership and, as applicable, partnership agreements, the names of officers, boards, charters, articles of organization and by-laws Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 4.3 Publicly Available Information 28.09(5)(a,b), (6) 18.04(1)(a)(b) 102 CMR 3.06(4)(b) The private special education school maintains the following in a place available for public and employee review: Valid safety inspections of all buildings by the Department of Public Safety or the local building inspector Health inspections Fire safety inspection from the local fire department Asbestos inspection PCB inspection A report demonstrating compliance with childhood lead poisoning prevention and control law and regulations, if applicable School’s policy and procedure manual Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 16 of 73 No CRITERION NUMBER Legal Standard Prior to any substantial change to the program or physical plant, the private school provides written notification to the Department to obtain approval. The program must also provide written notification to the Department of any sudden and/or unexpected changes that may impact the overall health or safety of students and/or the delivery of services required by IEPs. Examples of changes include, but are not limited to: a. Changes (e.g. increases or reductions) in services or staff including temporary staff shortages that alter the previously approved student/teacher (or student/childcare) ratios and/or affect the program or service delivery to students per their IEPs(if any changes occur in this area, the school must submit an updated Master Staff Roster); b. Building changes that affect the care of the students; 4.4 Advance notice of Proposed Program/ Facility Change 28.09 (5)(c) c. d. e. Major changes in the population to be served; Any alteration of the service configuration of the program as last approved by the Department; and Significant changes in program policies or procedures. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that Valleyhead School has not notified the Department that it has been unable to provide students with speech and language or occupational therapy when required by student individualized education program. CRITERION NUMBER Legal Standard 4.5 Immediate notification 18.03(10) 18.05(7) 28.09(12) For all students (regardless of state of residency), the private program makes immediate notification to the parent, the public school district special education administrator, and any state agency involved in the student care or placement (by telephone and letter), and the Department of Education (by telephone and Form 2) of the following incidents: a. Death of a student b. Hospitalization of a student, including outpatient emergency room visits, due to physical injury at school or previously unidentified illness, accident or disorder which occurs while the student is in the program c. Injury of a student in a motor vehicle accident d. In-patient psychiatric hospitalization of a student due to an emergency mental health crisis that occurs while the student is in the program e. Any time a medication error occurs (i.e. student misses a medication Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 17 of 73 CRITERION NUMBER Legal Standard f. g. h. i. administration, is administered the wrong medication, or is administered the wrong dose of medication) Running away of a student Emergency termination of a student including circumstances in which the student presents a clear and present threat to the health and safety of him/herself or others o A written termination summary explaining the reasons for the emergency termination must be sent to the parent(s), the student (if over 14 years of age), the local Administrator of Special Education, officials of the appropriate Human Service Agency and the Department of Education. Filing of a 51-A report with DSS, or a complaint to the Disabled Persons Protection Commission against the school or a school staff member for abuse or neglect of a student Any action taken by a federal, state or local agency that might jeopardize the school’s approval with the Department or any legal proceeding brought against the school or its employee(s) arising out of circumstances related to the care or education of any of its students regardless of state of residency Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School has developed a “Required Notification Chart” that includes contact information for persons and agencies that must be notified in case of specific incidents. This chart does not include all types of incidents that must be reported to the Massachusetts Department of Education. In interviews, staff members listed on this form as having responsibility to notify the Department of Education of reportable incidents were not aware of Massachusetts Department of Education procedures. Interviews indicate that immediate notification of all required incidents had not been made to the Department of Education or parents. AREA 5: ADMISSIONS PROCEDURES AND COORDINATION/COLLABORATION WITH SCHOOL DISTRICTS CRITERION NUMBER Legal Standard 5.1 The private special education program may not enroll eligible students under the Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 18 of 73 CRITERION NUMBER Legal Standard provisions of 603 CMR 28.00 unless approved to do so by the Department. Student Admissions The program develops and implements written admissions criteria, policies and procedures that include the following: a. A written statement describing how copies of the school’s policies and procedures are provided to the student (if applicable), parents and the placing school district prior to admission of the student. b. A statement that admissions policies and procedures are to be made available to parents and students at any time upon request c. Documentation from a licensed physician of a complete physical examination of the student not more than twelve (12) months before admission o In the event of emergency placements, the school shall make provisions for a complete examination of the student within thirty (30) days of admission. d. A narrative description of the student admission interview process e. Consent forms (See criterion 15.5) 28.09(11) 18.05(1) and (2) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that the policy on student admissions has not been updated since September 2005. It refers to the Department of Education approved Basic Care Program, which no longer exists. Interviews indicate that Valleyhead School would not admit a student who is pregnant and terminates the enrollment of a student if she becomes pregnant. CRITERION NUMBER Legal Standard 5.2 Policies and Procedures for Coordination /Collaboration with Public School Districts & Content s for Coordination The private special education program works collaboratively with the placing public school district to ensure that, to the maximum extent appropriate, children with disabilities are educated with children who do not have disabilities, are provided access to the general education program and are given opportunities to return to a less restrictive educational program. A private school shall have policies and procedures that describe roles and responsibilities of the program and its staff as well as general communication and collaboration procedures that address the following: a. Consideration of possible placement and admissions process; b. IEP development and implementation and roles in 3-year eligibility redeterminations; Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 19 of 73 CRITERION NUMBER Legal Standard /Collaboratio n with Public School Districts c. 28.06(2-3) 28.09(9)(c) &(d) 28.09(2)(b)7 e. f. Federal Regulations: 300.349 and 300.400-.401 28.06(2-3) 28.07(5) 28.09(9)(c) &(d) 28.09(2)(b)7 Federal Regulations: 300.349 and 300.400-401 d. g. h. i. j. k. l. Contents of and general arrangements for executing contracts with placing school districts; Participation of the private or public school program as well as school district representatives at the Team and other key meetings, including reviewing/revising the IEP; Written progress reports; Documentation regarding student-related developments, including matters involving students’ behavioral plans, functional behavioral assessments, manifestation determinations, imposition of discipline, etc. Administration of tests; Preparations for students returning to a public school or other less restrictive setting; Preparations for students approaching or reaching ages 14, 16 and 18, later education, and adult life, consistent with IDEA “transition” requirements and state age-of-majority law; School district monitoring of student progress; Granting of high school diplomas consistent with Department of Education requirements; and Conditions for issuance of certificates of attendance or program completion by a private school or educational collaborative. NOTE: Please review federal regulations 300.349 and 300.400-401 before preparing this policy/procedure. Public school districts have the lead responsibility for convening the Team that makes the initial and subsequent (every 3 years) eligibility determinations, develops the IEP, and decides upon an appropriate placement. Private and educational collaborative programs, however, play a major role in determining whether a proposed placement in the program will meet a student’s needs. Private and educational collaborative programs have the responsibility of delivering services on the IEP, assessing and communicating progress, developing subsequent IEPs and planning for the student’s return to a less restrictive environment and/or for adult life. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Interviews and student record review indicate that Valleyhead School does not have a current signed contract on file for each Massachusetts student enrolled. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 20 of 73 CRITERION NUMBER Legal Standard All staff with school district contact responsibility are trained regarding their particular roles and responsibilities. 5.4 Training 18.05(11)(g)(h) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard A senior person(s) is designated to communicate and work effectively with all public school districts that have placed students in the program. 5.5 Staff Coordinator 28.09(7) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that the Education Director is designated to have responsibility to communicate and work effectively with sending public school districts, but this position is currently vacant. Valleyhead School did not indicate which staff member is filling this responsibility in the interim until a qualified person is hired as the Education Director. AREA 6: EDUCATIONAL PROGRAM REQUIREMENTS -- STUDENT LEARNING TIME CRITERION NUMBER Legal Standard 6.1 Unless otherwise approved by the Department of Education, the private special Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 21 of 73 CRITERION NUMBER Legal Standard Daily Instructional Hours 603 CMR 27.00 education program provides an average annual minimum of the following instructional hours: Elementary: 5 hours per school day (except for kindergarten) Secondary: 5 ½ hours per school day The private special education program ensures that, unless a student’s IEP or Section 504 Accommodation Plan provides otherwise, each elementary school student is scheduled for at least 900 hours of structured learning time a year and each secondary school student is scheduled for at least 990 hours of structured learning time a year, within the required school year schedule. Where the private special education program operates separate middle schools, at the beginning of the school year it designates each one as either elementary or secondary. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School has developed three separate class schedules for students attending “The Farm,” the Comprehensive High School and the High School. Class offerings in summer months vary from those offered during the academic year. Observations and interviews indicate that the school day does not begin at the time indicated on the block schedule and students are not offered instruction in the subject area listed on the class schedules. During observed silent leisure reading time, students did not have books. Where the schedule at The Farm indicated students receive speech therapy or visual arts each Wednesday, interviews indicate that classes end at 1:10 and students watch a movie. On Mondays at The Farm, the class day ends at 2:30 when teachers have trainings. Observation at the main campus indicates that students who were scheduled to be on a recreational field trip were instead cleaning the classroom. CRITERION NUMBER Legal Standard 6.1(a) Physical Education Requirements The private special education program shall develop a curriculum to teach physical education as a required subject at all grade levels for all students for the purpose of promoting the physical well being of students. Both physical education and health education classes are to be considered part of the student’s structured learning time. MGL Chapter 71, Section 3 Rating: Partially Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 22 of 73 No Department of Education Findings: Documentation review indicates that Valleyhead School has not developed a written curriculum for physical education or health education. Review of class schedules and interviews indicate that Valleyhead School offers students a variety of physical education opportunities and is providing students with instruction in health. CRITERION NUMBER Legal Standard Where the private special education program counts independent study or a schoolto-work program as structured learning time, it has guidelines that explain clearly how hours spent by students are verified. 6.2 School-toWork 603 CMR 27.02, 27.04 Rating: Not Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School has not developed written guidelines for school to work activities that detail how hours spent in this experience will be verified, meet IEP goals and objectives or how students will receive supervision and feedback. CRITERION NUMBER Legal Standard 6.3 Kindergarten 603 CMR 27.03(5) Where the private special education program sets a separate school year and school day schedule for kindergarten programs, it provides at least 425 hours of structured learning time a year. If two sessions of kindergarten per day are scheduled, it ensures equal instructional time for all kindergarten students. Rating: Not Applicable RESPONSE REQUIRED: No Department of Education Findings: Valleyhead School is approved by the Massachusetts Department of Education to serve students age 12-22. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 23 of 73 CRITERION NUMBER Legal Standard The private special education program is conducted for the following days (exclusive of weekends, holidays, vacations): 10 month program - 180 days 11 month program – 198 days 12 month program – 216 days 6.4 School Days per Year 28.09(9) Before the beginning of each school year, the private special education program sets a school year schedule for each program. This schedule must include at least five additional school days to account for unforeseen circumstances (i.e. snowstorms). Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 6.5 Early Release of High School Seniors When a private special education program schedules the early release at the end of the year of the senior class of a high school, it does so in accordance with a written policy that conforms with Board of Education requirements under 603 CMR 27.05, ensuring that neither the conclusion of the seniors’ school year nor graduation is more than 12 school days before the regular scheduled closing date of that school. 603 CMR 27.05 Rating: Implemented RESPONSE REQUIRED: No AREA 7: EDUCATIONAL PROGRAM REQUIREMENTS -- CURRICULUM FRAMEWORKS AND STATE ASSESSMENTS CRITERION NUMBER Legal Standard 7.1 The program’s personnel shall reflect a full understanding of the connection between Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 24 of 73 CRITERION NUMBER Legal Standard the Massachusetts Curriculum Frameworks and the expectations of the state for student performance as well as the rights of students with disabilities to be full participants in the general curriculum. Curriculum Frameworks 28.09(9)(b) The program has taken steps to provide all students with essential learning opportunities that prepare the students to reach the state graduation standards. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Interviews indicate that not all educational staff and administrators have a full understanding of the connection between the Massachusetts Curriculum Frameworks and how the school will provide students with essential learning opportunities that prepare students to reach state graduation standards. CRITERION NUMBER Legal Standard The program shall ensure that all staff including non-professional staff have an understanding and knowledge of the general curriculum expectations and learning standards of the Massachusetts Curriculum Frameworks and shall incorporate such knowledge into the school’s educational program. 7.2 Staff Training 28.09 (9)(b) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 7.3 State/District Wide Assessments 28.09(9)(d) The program has a written procedure outlining how the school will ensure that all enrolled students participate in state and/or district wide assessments in accordance with the assessment participation information provided on the student’s IEP. Such procedures shall include how the approved program will provide for MCAS testing accommodations and/or administration of alternate assessments as determined by each student’s Team. Rating: Partially Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 25 of 73 Yes Department of Education Findings: Valleyhead School did not provide the Department of Education with documentation to indicate that teachers have attended training on providing MCAS alternate assessments. Interviews indicate that teaching staff members do not understand procedures for administering a portfolio assessment. AREA 8: EDUCATIONAL PROGRAM REQUIREMENTS -- INDIVIDUALIZED EDUCATION PROGRAMS CRITERION NUMBER Legal Standard 8.1 ImplementationEducational Services 28.04 and 28.09(8) 34 CFR 300.26 The program specifies how each of the following educational services are implemented for the described student population of the school: a. The content requirements of the Massachusetts Curriculum Frameworks; b. Self-help, daily living skills c. Social/emotional needs d. Physical education; adapted physical education e. Pre-vocational, vocational, and career education f. English language support (for limited English proficient students) g. Other: any other specialized educational service(s) provided by the program Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead School did not submit a written description of how it provides the educational services listed in this criterion. Interviews indicate that many of these services are being provided. CRITERION NUMBER Legal Standard 8.2 ImplementationRelated Services Related services are defined in the federal regulations as those services that are developmental and corrective as well as supportive services that assist a child to benefit from special education and/or access the general curriculum. 28.04 and 28.09(8) The program specifies how each of the following related services is or will be provided for the described student population of the school whose IEPs indicate Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 26 of 73 CRITERION NUMBER Legal Standard 34 CFR 300.24 such services: a. Transportation b. Braille needs (blind/visually impaired) c. Assistive technology devices/services d. Communication needs (all students including deaf/hard of hearing students) e. Language needs (Limited English Proficient students) f. Physical therapy g. Occupational therapy h. Recreation services i. Mobility/orientation training j. Psychological services, counseling services, rehabilitation counseling services, social work services k. Parent counseling and training l. School health services, medical services m. Other (e.g., music therapy, sensory integration therapy) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead School did not submit a written description of how it provides the related services listed in this criterion. Interviews indicate that, although the school has recently been unable to provide all required speech and language or occupational therapy services, many of these services are being provided. CRITERION NUMBER Legal Standard 8.3 ImplementationSupplementary Aids/Services 34 CFR 300.28 Supplementary aids and services are defined as “those aids and services – which are not ‘specially designed instruction or related services’ – which enable eligible students to be educated to the maximum extent possible with non-disabled students.” The program provides examples (through a list or narrative) of the kinds of supplementary aids and services that are available for students in the program. These may include aids and services that would typically be available in a less restrictive setting, and their availability would be helpful when the student is able to be placed in a less restrictive placement (e.g. adapted text, enlarged print, graph paper, peer tutor, etc.). Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 27 of 73 No CRITERION NUMBER Legal Standard 8.4 Program Modifications and Support Services for Limited English Proficient Students TITLE VI: 42 U.S.C. 2000D; 34 CFR 100.3(A),(B); EEOA: 20 U.S.C. 1703(F); M.G.L. C. 71, S. 38Q1/2; 603 CMR 28.03(3)(A); M.G.L. C. 71A, SS. 2(E), 4; 603 CMR 14.04; M.G.L. C. 76, S. 5; 603 CMR 26.03 The private special education program implements necessary program modifications and support services to serve effectively limited English proficient (LEP) students who need special language assistance. Such program modifications and support services: a. Are based on sound education theory; b. Provide for English-language development; c. Provide for meaningful participation of LEP students in the school’s educational program; d. Are evaluated and appropriately revised in an ongoing manner; and e. Are demonstrably useful in assisting students receiving such program modifications and services to gain English language proficiency. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 8.5 Current IEP & Student Roster The program has on file a current IEP for each enrolled Massachusetts student that has been issued by the responsible public school district and consented to by the student’s parent(s), legal guardian (or student, when applicable). 28.09 Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 28 of 73 No CRITERION NUMBER Legal Standard 8.6 Educational Case Manager The program shall assign an educational case manager to each student. 28.09 Rating: Not Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Student record review and interviews indicate that Valleyhead School has not assigned an educational case manager to each student. CRITERION NUMBER Legal Standard 8.7 IEP Implementation The program shall implement all services on the students’ IEPs. 28.09 Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Interviews indicate that Valleyhead School is not currently ensuring that students who have speech and language or occupational therapy services required in their individualized education program are receiving them. CRITERION NUMBER Legal Standard 8.8 IEP – Progress Reports The program shall send copies, at least quarterly, of progress reports to the parents and public school (if student is in a collaborative or private placement). Such reports must include written information on the student’s progress toward the Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 29 of 73 CRITERION NUMBER Legal Standard 28.07(3) 20 U.S.C. Chapter 33, Section 1414(d)(1)(A) (viii) IDEA Regulations: 300.347 annual goals in the IEP (specifying each quarter), including information on the extent to which such progress is sufficient to enable the child to achieve the goals by the end of the year. Copies of progress reports shall be maintained in student records, including documentation of persons or agencies receiving such reports. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Interviews and student record review indicate that progress reports written by staff members at The Farm address student progress toward meeting IEP goals. Those written by staff on the main campus do not address progress toward IEP goals. Quarterly reports are not consistently placed in student records as per the school’s written policy. CRITERION NUMBER TOPIC Legal Standard 8.9 IEP – Revisions & Changes 34 CFR 300 The program notifies the responsible public school district and parents whenever the IEP needs to be revised to reflect a change in goals, placement, or a return to a less restrictive setting. In no case shall the private school or educational collaborative provide notice of a Team meeting required by state and federal special education requirements. In no case shall the private school or educational collaborative conduct a Team meeting without the authorization and presence of an administrative representative of the responsible school district. In no case shall the private school or collaborative issue a new or revised IEP for a student. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Student record review and interviews indicate that Valleyhead School does not alert the sending school district that IEP Team may need to be reconvened and the IEP revised because the student is receiving failing grades or failing to make sufficient progress toward IEP goals and objectives. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 30 of 73 CRITERION NUMBER Legal Standard The program has a plan for ensuring that there are flexible procedures and mechanisms that maximize opportunities for enrolled students to gain the capacity to return to a less restrictive educational program. Such mechanisms may include, but are not limited to, a capacity for part-time attendance at a public school or in a general education classroom, or other community program, or a period of transition from one program option to a less restrictive program option. 8.10 IEP – Less Restrictive Placement 28.09(9)(c) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead did not provide the Department of Education with a written plan for providing students with opportunities to participate in a less restrictive educational program, but interviews indicate that Valleyhead School has worked with Lenox Public Schools and other community programs to provide students with these opportunities. CRITERION NUMBER Legal Standard 8.11 IEPTransition Planning 34 CFR 300.347(b)(1) 34 CFR 300.347(b)(2) No later than when a student is 15 years old, the program works with the responsible school district to discuss a student's transition needs at the IEP Team meeting. If appropriate, the Team considers and writes specially designed, measurable goals based on age-appropriate transition assessments related to training, postsecondary education, employment, and, where appropriate, to independent living skills. If transition services are included in the IEP, they are based upon the student's needs, taking into account the student's preferences and interests, and may include employment or other post-school adult living objectives, and the acquisition of daily living skills and functional vocational evaluation. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School has a policy on transition planning that does not reflect changes in IDEA 2004. Student record review indicates that very few records include a transition planning chart. Interviews indicate that staff members who attend IEP Team Meetings are not aware of the requirement to discuss and document transition goals on the transition planning form. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 31 of 73 CRITERION NUMBER Legal Standard For students approaching graduation or the age of twenty-two, the private school’s participant on the IEP Team will provide sufficient information to the Team to enable the Team to determine whether the student is likely to require continuing services from adult human service agencies. 8.12 IEP – Transition Services 28.05(4)(c) The private or public school may make the referral to the Bureau of Transitional Planning in the Executive Office of Health and Human Services (at least two years prior to the student’s 22nd birthday) in accordance with the requirements of MGL c.71, §12-A-§12C (known as Chapter 688). Rating: Implemented RESPONSE REQUIRED: No AREA 9: EDUCATIONAL PROGRAM REQUIREMENTS -- STUDENT DISCIPLINE AND BEHAVIOR MANAGEMENT CRITERION NUMBER Legal Standard 9.1 Policies and Procedures 18.05 (5) The program develops a comprehensive set of policies and procedures dealing with discipline and behavior management that meet all federal special education requirements, and all applicable state and federal requirements pertaining to the use of restraint. (See Criterion 9.4 below.) These policies and procedures are consistently implemented. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Comment: Documentation review indicates that Valleyhead’s behavior management philosophy is based on “natural rewards and consequences.” Procedures to implement this therapeutic behavior change model could not be clearly articulated by all staff members who were interviewed. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 32 of 73 CRITERION NUMBER Legal Standard The private special education program develops and implements a student discipline code of conduct. 9.2 Discipline Code Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard The program shall have a written policy, including a definition of runaways, appropriate for the school population and location, as well as procedures for handling students who run away. 9.3 Runaway Students These policies must be approved by the Department of Education. 18.03 (10) The school must notify the Department, the local school district and/or other involved agencies and parents immediately whenever any student runs away. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 9.4 Restraints A private day educational program must develop a policy on the use of physical restraint and administer physical restraint in accordance with the requirements of 603 CMR 46.00. 18.05 (5) 603 CMR 46.00 A residential educational program and any day educational program operated by a residential program must comply with the OCCS restraint requirements contained in 102 CMR 3.00 for all students enrolled in such program. A private school educational program within a program or facility subject to M.G.L. c. 123 or Department of Mental Health Regulations must comply with the restraint requirements of M.G.L. c. 123, 104 CMR 27.12 or 104 CMR 28.05, where applicable. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 33 of 73 CRITERION NUMBER Legal Standard Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Interviews indicate that staff members do not understand Department of Education notification requirements when a staff member or student is injured during a restraint. CRITERION NUMBER Legal Standard 9.5 3-5 Day Suspensions 18.05(6) Upon admission of a student, the private special education program shall provide a written policy on suspensions to the parents and to the school district and human service agency that placed the student. Such policy shall also contain the following information: a. Whenever a student is suspended, the school shall immediately notify the parents and the public school or human service agency responsible for the placement. Within 24 hours, the school shall send a written statement explaining the reasons for suspension to the parents and public school district. b. No student may be suspended and sent home unless a responsible adult is available to receive the student. c. Once a student has been suspended for three (3) consecutive school days or five (5) non-consecutive school days in a school year, the school, parents, and public school district, consistent with federal requirements, shall explore together all possible program modifications within the school in an attempt to prevent more lengthy suspension of the student from the program. d. Procedures must be in place to record and track the number and duration of suspensions, including suspensions from any part of the student’s IEP program (including transportation). NOTE: Sending a student home “early” is considered a suspension if the student’s IEP does not allow for the modification of learning time requirements of the Board of Education. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 34 of 73 No CRITERION NUMBER Legal Standard 9.6 Suspensions Joint responsibilities of the public/ private school and the responsible school district Federal Requirements: 34 CFR 300.519-.529 The private special education program implements the following procedures when suspensions exceed 10 consecutive school days or a pattern has developed for suspensions exceeding 10 cumulative days: a. b. c. d. e. A request is made of the student's responsible school district to convene an IEP Team meeting, which includes representation from the private school, prior to a suspension that constitutes a change in placement of a student with disabilities; The private school participates in the Team meeting: o To develop or review a functional behavioral assessment of the student’s behavior and to develop or modify a behavior intervention plan; o To identify appropriate alternative educational setting(s); and To conduct a manifestation determination (i.e. to determine the relationship between the disability and the behavior). [To do this, the Team asks questions including: Is the IEP appropriate? Is the placement appropriate? If there was a behavior plan, was it implemented? Does the student understand the impact and consequences of his/her behavior? Can the student control his/her behavior?]. If the Team determines that the behavior is NOT a manifestation of the disability, the school may suspend or terminate the student consistent with policies applied to any other student in the program. The responsible school district must, however, offer an appropriate education program to the student with disabilities that may be in some other setting. If the TEAM determines that the behavior IS a manifestation of the disability, the placing district, in coordination with the private school, takes steps (with the consent of the parent) to modify the IEP, the behavior intervention plan, and/or the placement. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 9.7 Terminations The private special education program shall not terminate the enrollment of any student, even in emergency circumstances, until the enrolling public school district is informed and assumes responsibility for the student. 28.09(12) 18.05(7) The program develops a written termination policy that includes, but is not limited to, the following: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 35 of 73 CRITERION NUMBER Legal Standard a. b. c. d. At the request of the public school district, the program shall delay termination of the student for up to two (2) calendar weeks to allow the public school district the opportunity to convene an emergency Team meeting or to conduct other appropriate planning discussions prior to the student’s termination. With mutual agreement between the private special education program and the placing public school district, termination of enrollment may be delayed for longer than two calendar weeks. For planned terminations, the private special education program shall notify the public school district of the need for an IEP review meeting and provides notice of this meeting to all appropriate parties ten (10) days in advance of the intended date of the meeting. The purpose of the meeting will be to develop a clear and specific termination plan for the student that shall be implemented in no less than thirty (30) days unless all parties agree to an earlier termination date. For emergency terminations, which are circumstances where the student presents a clear and present threat to the health and safety of him/herself or others, the program shall follow the procedures required under 603 CMR 28.09(12)(b) and immediately notify the Department of Education. Rating: Implemented RESPONSE REQUIRED: No AREA 10: EDUCATIONAL STAFFING REQUIREMENTS -- STUDENT:TEACHER AND STUDENT:CHILDCARE WORKER RATIOS CRITERION NUMBER Legal Standard 10.1 Student: Teacher Ratios 28.06(6)(d)& (g) 28.09(7)(e) Unless otherwise approved by the Department of Education, the private special education program ensures that instructional groupings do not exceed: 8 students to one certified teacher without an aide 12 students to one certified teacher with an aide Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 36 of 73 CRITERION NUMBER Legal Standard Rating: Implemented RESPONSE REQUIRED: No Department of Education Comment: Review of Valleyhead’s policy indicates that the private school maintains ratios within the guidelines of this Department regulation and has not requested alternate student to teacher ratios. Interviews indicate that the student to teacher ratio is 5:1. CRITERION NUMBER Legal Standard The program shall ensure that the ages of the youngest and oldest child in any instructional grouping shall not differ by more than forty-eight months (4 years). 10.2 Age Range 28.06(6)(f) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that the age range of students at The Farm and the Comprehensive High School exceed forty-eight months and Valleyhead School had not requested a waiver to this regulation from the Department of Education prior to placing students in these classroom groupings. CRITERION NUMBER Legal Standard 10.3 Programs for Young Children The program shall ensure that any and all substantially separate classrooms for young children (3 and 4 year olds) do not exceed nine (9) students with one teacher and one aide. 28.09(7)(e) 28.06(7) Rating: Not Applicable RESPONSE REQUIRED: Department of Education Findings: Valleyhead School is approved by the Department of Education to serve students age 12-22. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 37 of 73 No CRITERION NUMBER Legal Standard The program has a student to childcare worker ratio of: Not lower than 4:1 nor greater than 6:1 during non- “school day” waking hours Not lower than 6:1 nor greater than 8:1 during sleeping hours 10.4 Student: Child Care Ratios 28.09(7) 18.01(2) Rating: Implemented RESPONSE REQUIRED: No Department of Education Findings: Review of Valleyhead’s policy indicates that the private school maintains student to child care ratios as required by this Department of Education regulation. CRITERION NUMBER Legal Standard 10.5 Alternative Ratios 18.03(2) Where applicable, the private special education program shall submit a justification for alternative ratios for student to childcare workers, and the Department shall approve or disapprove these at its discretion. Rating: Not Applicable RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 38 of 73 No AREA 11: EDUCATIONAL STAFFING REQUIREMENTS -- PERSONNEL POLICIES, QUALIFICATIONS, RESPONSIBILITIES CRITERION NUMBER Legal Standard 11.1 Personnel Policies 28.09(7) 28.09(11)(a) 18.05(11) The private special education program shall develop written personnel policies and procedures that describe: a. Criteria and procedures for hiring, written evaluations, suspension or dismissal of any staff person; and development of teacher and staff evaluation forms; b. Procedures for handling staff complaints; c. Provisions for vacations, holidays, leaves, sick days, and any other benefits offered by the program; d. A plan for using volunteer and/or intern services; e. Equal employment/educational opportunities/affirmative action in regard to race, color, creed, national origin, sex, sexual orientation and handicap; and f. Consistent with state law effective on February 25, 2003, procedures for accessing, considering and acting upon Criminal Offender Record Information (CORI), for current and prospective employees, volunteers, school transportation providers and others who may have direct and unmonitored contact with students. [NOTE: For applicants or employees who reside outside of Massachusetts, approved special education schools should obtain and review criminal record information from the state of residence of the applicant or employee on the same basis as it does for applicants and employees who reside in Massachusetts.] Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead has a policy to conduct a written evaluation for each staff member after 90 days of initial employment and annually thereafter. An annual evaluation conducted in the previous 12 months was not found in the sample of personnel files reviewed. The Personnel Manual does not contain a plan for use of volunteers and interns, although interviews indicate that these persons are involved with students at Valleyhead. The Personnel Manual does not contain a policy on conducting CORI checks, although interviews indicate that these are consistently conducted. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 39 of 73 CRITERION NUMBER Legal Standard 11.2 Administrative Responsibility The private special education program shall designate one person who will have administrative responsibility over the operation of the school. Schools with more than 40 professional licensed staff may have one (or more) assistant administrator(s) provided the Department approves such positions. 18.05(11)(a) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Comment: Valleyhead School submitted conflicting information to the Department of Education about the administrative leadership of its approved program. A narrative provided to the Department states that the Educational Director has administrative responsibility over the operation of the school. Review of the organization chart, as well as information gathered from interviews, indicate that that the Executive Director and Chief Operating Officer have administrative responsibility over the operation of the school, under the direction of the President and Chief Executive Officer. CRITERION NUMBER Legal Standard 11.3 Educational Administrator Qualifications 28.09(7)(a) 603 CMR 44.00 and 44.04 The program shall designate an educational administrator to supervise the provision of special education services in the school and to ensure that the services specified in each student’s IEP are delivered. The educational administrator either shall have licensure as a special education administrator or all of the following: A current license as a special educator; A minimum of a master's degree in special education or a related field; and A minimum of one year of administrative experience. The educational administrator shall be re-licensed pursuant to the requirements of 603 CMR 44.00. The educational administrator shall obtain supervisory approval of his/her Professional Development Plan per 603 CMR 44.04. Rating: Not Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that the position of Educational Administrator is currently vacant. Valleyhead does not have qualified staff members who can assume the responsibilities of the Educational Director until this position can be filled. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 40 of 73 CRITERION NUMBER Legal Standard 11.4 Teachers (Special Education Teachers and Regular Education Teachers) 28.09(7)(b)(c) 18.05(11)(f) The private special education program must ensure that all teaching staff have teaching license (certification) appropriate to meet the needs of the population being served pursuant to the requirements of 603 CMR 7.00 and, additionally, must adhere to the following requirements: a. All teaching staff shall be re-licensed pursuant to the requirements of 603 CMR 44.00 and shall be subject to the same requirements as teachers in Massachusetts public schools and shall be required to obtain supervisor approval of Professional Development Plans pursuant to 603 CMR 44.04. b. At least half of the teaching staff shall be licensed in special education areas appropriate to the population served at the school; other teaching staff shall be licensed in other educational areas, in order to provide for content expertise in the general curriculum. The Department of Education may require a higher proportion of licensed special educators if, in the opinion of the Department, the population requires more specialized services. c. To the extent that teaching staff is providing special education services, such services shall be provided, designed, or supervised by a special educator. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation and personnel record as well as interviews indicate that not all of the school’s seven teachers has a license to teach the subject they are teaching. Fifty percent of teachers do not have a current license or waiver in special education. Interviews indicate that teaching staff members do not understand procedures to maintain their teaching licensing or waiver. CRITERION NUMBER Legal Standard 11.4(a) Professional Development Plans All licensed teaching staff holding professional licensure shall be required to obtain supervisor approval of Professional Development Plans pursuant to 603 CMR 44.04. 28.09(7)(b)(c) 18.05(11)(f) Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 41 of 73 CRITERION NUMBER Legal Standard Rating: Not Applicable RESPONSE REQUIRED: No Department of Education Findings: Documentation review and interviews indicate that Valleyhead School does not currently employ teachers who hold a professional level license. CRITERION NUMBER Legal Standard 11.5 Related Services Staff 28.09(7)(d) All staff providing or supervising the provision of related services shall be appropriately certified, licensed or registered by their respective state boards or professional associations and the Department of Education, when appropriate. Rating: Not Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead School did not submit a copy of a current license for all related services providers. CRITERION NUMBER Legal Standard 11.6 Master Staff Roster 28.09(7) The private special education program maintains a master list of ALL staff for every position within the program. This list must include job titles along with their corresponding UFR title numbers for private programs, staff qualifications, and fulltime equivalents (FTE’s) for public and private programs. This list may include, but is not limited to: Administrators Special education teachers General education teachers Related services professional staff Registered Nurse Direct (child) care workers Direct (child) care supervisors Clerical and maintenance staff Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 42 of 73 Psychologist Social worker Food service staff Consultants Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard The public/private special education program has written job descriptions for all staff positions that shall be made available to staff as well as parents, if requested. 11.7 Job Descriptions 18.05(11)(d) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard The program shall establish in writing a salary range including benefits covering all positions and shall inform each employee of the same for his/her position. 11.8 Salary Ranges 18.05(11)(e) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 11.9 Organization al Structure The program shall demonstrate that its organizational structure provides for the effective and efficient operation of the school, supervision of school staff, and supervision of students. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 43 of 73 CRITERION NUMBER Legal Standard 28.09(7) 28.07(c) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: The organizational structure of Valleyhead School does not provide for the effective communication of among the educational, clinical and residential components of the program and the agency is not staffing the program as it was approved by the Department of Education. The position of Education Administrator is vacant and appropriate supervision of teachers and the educational program is not provided by qualified persons. Documentation review and interviews indicate that teacher assistants are supervised by the residential director on the main campus and by the Program Director at The Farm. Also, the residential director does not supervise residential staff at The Farm. There is a Program Director at The Farm, but no equivalent position at the main campus. The Organizational Chart includes a position for residential coordinator, but this position was not referred to by staff in interviews. Information on important changes to student medications is not effectively communicated from clinical staff to educational and residential staff members CRITERION NUMBER Legal Standard 11.10 Supervision of Child Care Workers (Direct Care Staff) Each program shall provide ongoing and regular supervision of all childcare workers by a professional staff person who has supervisory and administrative responsibility within the school. 18.03(4) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 11.11 Supervision of The program shall develop and implement a detailed plan that describes how appropriate supervision is provided to students while they are engaged in any Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 44 of 73 CRITERION NUMBER Legal Standard school-related activity on and off school grounds. This plan must include arrangements for individual and group recreational programs appropriate to the age, interests, and needs of each student with assigned staff as appropriate. Students 28.09(7) 18.03(1) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead’s policy on Off-Ground Trips states that two staff members must accompany a resident. Interviews indicate that this staff to student ratio is often not implemented when students participate in activities in the community. CRITERION NUMBER Legal Standard 11.12 Accessibility of Extracurricular Activities Title VI: 42 U.S.C. 2000d; 34 CFR 100.3(a), (b); Title IX: 20 U.S.C. 1681; 34 CFR 106.31, 106.41; Section 504: 29 U.S.C. 794; 34 CFR 104.4,104.37(a), (c); Title II: 42 U.S.C. 12132; 28 CFR 35.130; NCLB: Title X, Part C, Sec. 721; Mass. Const. amend. art 114; M.G.L. c. 76, s. 5; 603 CMR 26.06 Extracurricular activities sponsored by the private special education program are nondiscriminatory in that: The school provides equal opportunity for all students to participate in intramural and interscholastic sports Extracurricular activities or clubs sponsored by the school do not exclude students on the basis of race, sex, color, religion, national origin, sexual orientation, disability, or homelessness Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 45 of 73 No CRITERION NUMBER Legal Standard 11.13 Plan for Staff Coverage Each program must provide a detailed description of how the school will provide childcare and/or overall staff coverage in the absence of workers due to illness, staff vacancies, emergencies, or other unexpected circumstances. 18.03(1)(b)4 Rating: Implemented RESPONSE REQUIRED: No AREA 12: EDUCATIONAL STAFFING REQUIREMENTS -- STAFF TRAINING CRITERION NUMBER Legal Standard 12.1 Staff Orientation Training The private special education program develops a written plan for staff orientation and provides an orientation-training program for all new staff to ensure an understanding of the school’s philosophy, organization, program, practices and goals. 18.05(11)(g) The written plan shall describe how newly hired staff are provided training on all required topics at the time of hire if the required topics have already been covered with existing staff. *New staff may not be assigned direct care duties with students until they have participated in all mandated training through their orientation program. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 46 of 73 No CRITERION NUMBER Legal Standard 12.2 Annual InService Training Plan and Calendar The private special education program develops and implements a written plan for staff orientation and training that is consistent with the needs of the student population, appropriate to the role of each staff member and provides, on average, at least two (2) hours per month of relevant training for all staff including nonprofessional staff (child care workers/direct care staff on all shifts). Staff input on training needs is elicited and considered. 28.09(7)(f) 18.05(11)(h) The following topics are required in-service training topics and must be offered annually to all staff providing direct care services to students: a. Reporting abuse and neglect of students to the Department of Social Services (51-A) and/or the Disabled Persons Protection Commission; b. Emergency first aid training by a certified instructor and, where specifically required by the Department of Education, certification in CPR; c. Medication administration (including, but not limited to, administration of antipsychotic medications and discussions of medications students are currently taking and their possible side effects); d. Runaway policy; e. Transportation safety (if applicable); f. Student record policies and confidentiality issues; g. Evacuation policies and emergency procedures including, but not limited to, utilization of the alarm system, evacuations in instances of fire or natural disaster; h. Behavior management policies and procedures used by the program such as positive reinforcement, point/level systems, token economies, time-out procedures; i. Restraint procedures including de-escalation methods used by the program; j. Curriculum alignment with the Massachusetts Curriculum Frameworks; k. Procedures for inclusion of all students in MCAS testing and/or alternate assessments; and l. Civil rights responsibilities. Title VI: 42 U.S.C. 2000d; 34 CFR 100.3; EEOA: 20 U.S.C. 1703(f); Title IX: 20 U.S.C. 1681; 34 CFR 106.31106.42; M.G.L. c. 76, s. 5; 603 CMR 26.00, esp. 26.07(2), (3) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead School did not submit a yearly schedule for provision of mandated trainings. This was also a finding at the time of the 2001 Program Review. Personnel record review indicates that training in first aid, CPR, restraint, behavior management, curriculum frameworks and MCAS are documented, but documentation of annual trainings on other required topics were rarely found and all staff are not receiving at least 24 hours of training per year. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 47 of 73 CRITERION NUMBER Legal Standard 12.2 (a) Details Behavior Management and Restraint Training 28.09(11) 18.05(5) Training on behavior management and suspension and termination procedures includes: a. Program’s student conduct/discipline code b. Description of safeguards for students’ emotional, physical, and psychological well-being c. Policies on use of time-out procedures d. Techniques for dealing with disruptive and violent behavior including skill training on the proper use of non-violent restraint e. Detailed procedures pertaining to the use of any type of restraint, which must meet or exceed any requirements in applicable state regulations or policy * f. Procedures for obtaining and recording data regarding student discipline and behavior along with a description of how such data will be integrated into IEP Team discussions g. Procedures for obtaining parental consent, if appropriate *NOTE: OCCS residential regulations on behavior management, including restraint and timeout, are found at 102 CMR 3.07(7). The provisions relating to restraint are expanded in EOHHS/OCCS’s “Guidelines for Physical Restraint” issued 1/11/00. DMH regulations regarding restraint may apply to schools serving DMH clients. DOE Regulations on the Use of Restraints in Publicly Funded Education Programs [603 CMR Section 46.00] apply to a private day programs approved by the Department of Education where such program does not hold the approval of the Department of Education as a residential school.) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 12.2 (b) Child Abuse Reporting 18.05(9)(j) The program has written procedures and staff training for the reporting of suspected child/student abuse or neglect to the Department of Social Services (MGL c.119, s. 51A) and the Disabled Persons Protection Commission (MGL c. 19C). Such procedures include notification to the Department of Education when a report is filed against the program or its employee(s). Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 48 of 73 No CRITERION NUMBER Legal Standard The program shall develop written policies and procedures for annual basic/emergency first aid training for all direct care staff. Where specifically required by the Department of Education, direct care personnel maintain appropriate CPR certification. 12.2(c) Details CPR Certification and Emergency First Aid Training 18.05(9)(e) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead did not submit a list of direct care personnel, updated annually, which includes the date and location for CPR and first aid training or the name and qualification of the trainer. Interviews and personnel record review indicate that staff members hold current first aid and CPR licenses. CRITERION NUMBER Legal Standard 12.2(d) Details Medication Training 18.05(9)(f)(3) (c) Training by a physician or registered nurse shall be given to all staff who provide care and instruction to students receiving medication. The training shall include the nature of a medication, potential side effects and any special precautions or requirements. (Note: See requirements for health care manual, which must include policies and procedures on medication administration.) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School has a policy on medication administration that meets Department of Education standards; however interviews indicate that staff members do not receive refresher training in administration of medication by a registered nurse or physician. Interviews indicate that Valleyhead School has not developed a method to immediately inform all residential, education and clinical staff of medication changes and potential side effects to be monitored and reported. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 49 of 73 CRITERION NUMBER Legal Standard The private special education program shall train staff to keep current and complete files for each publicly funded enrolled student and shall train staff to manage such files consistent with the Massachusetts Student Record Regulations (603 CMR 23.00) and MGL c.71, s.34H. 12.2(e) Student Record Training 28.09(10) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard All staff shall be trained relative to emergency procedures, evacuation policies and procedures and in the use of the alarm system and equipment such as fire extinguishers. 12.2(f) Emergency Procedures Training 18.05(10) The program shall conduct at least two evacuation drills per shift at each location annually (including all day programs, and residences in the evening and overnight) to ensure that all students are able to leave the building safely. In addition, the program shall: a. Help all students to understand the nature of the drills b. Make special provisions for the evacuation of any mobility-impaired student in the facility c. Keep a written log of each evacuation drill which includes date, time elapsed, participants (students and staff), witnesses, etc. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 12.2(g) Interns and Volunteers If applicable, the training plan includes provisions for the orientation, training and supervision of interns, volunteers or others who work at the program. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 50 of 73 CRITERION NUMBER Legal Standard Training 18.05(11)(i) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Valleyhead School has not developed a written plan on the orientation, training and supervision of interns and volunteers. Interviews indicate that the school does have volunteers and interns who participate in the program. CRITERION NUMBER Legal Standard 12.2(h) Child Care Staff Development and Training The private special education program shall develop and implement with staff input a detailed written plan for staff development and in-service training of all childcare workers. 18.03(3) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Personnel record review indicates that child care workers on all shifts are not receiving training in mandated topics. CRITERION NUMBER Legal Standard Written performance evaluations shall be scheduled and maintained for all staff as outlined in the program’s Personnel Policy and Procedures Manual. 12.2 (i) Staff Evaluations 18.05(11)(c)1 Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 51 of 73 CRITERION NUMBER Legal Standard Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that a written policy for performance evaluations requires that they be conducted 90 days after initial hire and annually thereafter, but performance evaluations have not been conducted in the previous 12 months. AREA 13: PHYSICAL FACILITY AND EQUIPMENT REQUIREMENTS CRITERION NUMBER Legal Standard 13.1 Educational Facilities and Materials 28.09(8) The private special education program shall provide the facilities, textbooks, equipment, technology, materials and supplies needed to provide the special education and related services specified on the IEP’s of enrolled students. If specialized materials or equipment are needed solely for an individual student, the program may enter into an agreement for the provision of such materials or equipment by the school district enrolling the student. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 13.2 Description of Physical Facility 28.09 (8) 18.04 A narrative description and floor plans of all buildings for each school and/or program (including residences) are provided, including number of floors, room numbers, types and sizes of rooms (i.e. classrooms, time-out rooms, counselingtherapy rooms, tutorial rooms, physical education facilities and other specialized service delivery spaces for school buildings, bedrooms, bathrooms, kitchen area, dining area, and living areas for residences). Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 52 of 73 CRITERION NUMBER Legal Standard Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 13.3 Comparability of Facilities Title VI: 42 U.S.C. 2000d; 34CFR 100.3(b)(2); Title IX: 20 U.S.C. 1681; 34CFR 106.33,106.40 (b)(3); Section504: 29]U.S.C. 794; 34CFR 104.34(c); Mass. Const. amend. art. 114; 603 CMR 28.03(1)(b) Where the private special education program provides separate facilities for members of a specific group, those facilities are comparable to those offered other students in the program, including: Separate facilities for disabled, limited English proficient or pregnant students that are comparable to the facilities for other students in the program; and Separate toilet, locker room, and shower facilities for students of one gender that are comparable in size, condition, number and location to those provided to students of the other gender. Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 13.4 Physical Facility/Archi tectural Barriers The private special education program shall assure that students with limited mobility have access, free from barriers to their mobility, to those areas of the school buildings and grounds to which such access is necessary for the implementation of the IEPs for such students. All schools receiving federal funds shall meet the requirements of Section 504 of the Rehabilitation Act of 1973. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 53 of 73 CRITERION NUMBER Legal Standard 18.04(8) Section 504: 29 U.S.C. 794; 34 CFR 104.21,104.22 ; Title II: 42 U.S.C. 12132; 28 CFR 5.149, 35.150; Mass. Const. amend. art. 114 If any part of the program is not accessible to students with limited physical mobility, a plan and timetable is provided that describes how the school will make all programs and appropriate buildings accessible. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Observation indicates that Valleyhead School does not have a residence building on The Farm or the main campus that is fully handicapped accessible. Documentation review indicates that Anderson House, a former residential building, is being renovated and will contain a residence that is fully handicapped accessible. The written plan to provide access to all educational programs for a student with limited physical mobility is to relocate classes to a location that has handicapped accessibility to classes, but does not have an accessible bathroom. CRITERION NUMBER Legal Standard 13.5 Kitchen, Dining, Bathing/ Toilet and Living Areas 18.04(2),(3), (4),(5) The private special education program shall ensure that all kitchen, dining, bathing/toilet and living areas are of an adequate type, size and design appropriate to the ages and needs of the students. The program shall also: a. Maintain areas which are clean, well ventilated and free from hazards; b. Provide students with equipment, supplies and materials (e.g. kitchen equipment, dining utensils, toilets, sinks, individual furniture and storage space) which are clean, safe and appropriate to the ages and needs of the students; c. Design all living areas to simulate the functional arrangements of a home and to encourage a personalized atmosphere for small groups of students, unless the school can justify that another arrangement is necessary to serve the particular needs of the students enrolled in the school; and d. Post a list of student food allergies in all appropriate areas of the residence. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 54 of 73 CRITERION NUMBER Legal Standard Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Observation indicates that one residence on the main campus had holes in doors and walls as well as missing floor tiles. Common living area spaces in all residences are small for the number of students. CRITERION NUMBER Legal Standard Each room or area that is utilized for the instruction of students shall be adequate with respect to the number of students, size and age of students and students’ specific educational needs, physical capabilities and educational/vocational activities. 13.6 Classroom Space 18.04(6)(a) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Observation indicates that classroom spaces are not adequate in size at the Comprehensive High School in Coach House or at The Farm. Classrooms at the Coach House have 8 students with 3-4 staff members. The classroom at The Farm had 12 students with 3-4 staff members. High school classrooms are designed to have 5 students with one teacher, but in the summer months classes were observed to have eight students with 2 teachers; classroom size is not adequate for this number of people. Observation indicated that the classroom in the Coach House is not safe and appropriate for instruction because of holes in the wall and the floor under a student’s chair. CRITERION NUMBER Legal Standard 13.7 Library/ Resource Room In addition to the regular instructional area, the school shall have a library or resource room (or comparable instructional resource area approved by the Department of Education) that contains a variety of materials appropriate to the age and abilities of the students enrolled. 18.04(6)(b) Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 55 of 73 CRITERION NUMBER Legal Standard Rating: Not Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School was cited six years ago during the 2001 Program Review for the lack of designated library and resource space. The school was again cited by the Department of Education at the time of the 2004 Mid-cycle for not implementing its approved corrective action plan to develop a library and resource space. In June 2006, the Department of Education conducted an onsite visit and notified the school that no progress had been made in the establishment of a library. Although documentation submitted to the Department of Education for this review states that the development of the library is underway, observation of the library space indicates that it is currently an empty room without furniture or materials. CRITERION NUMBER Legal Standard 13.8 Indoor Space 18.04(7)(a) The school shall have a minimum of thirty-five (35) square feet of activity space per student exclusive of hallways, lockers, toilet rooms, isolation rooms, kitchen, closets, offices or areas regularly used for other purposes. Additionally, all programs must: a. Ensure that all areas, including but not limited to, floors, ceilings and walls, are clean, well maintained and free from safety hazards; b. Protect all steam and hot water pipes by permanent screen guards, insulations, or any other suitable device which prevents students from coming in contact with them; c. Maintain room temperatures at not less than 68 degrees Fahrenheit at zero Fahrenheit outside and at not more than the outside temperature when the outside temperature is above 80 degrees Fahrenheit; and d. Designate space separate from classroom areas for administrative duties and staff or parent conferences. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Observation indicates that there are holes in the walls and floor of the classroom in Coach House and the Stow House residence has holes in doors and walls as well as broken floor tiles. Room temperatures were observed to be in access of 80 degrees at the time of the review. Each residence at the main campus had one window air conditioner for the living room area, but this was not adequate to cool student bedrooms. At The Farm, one window air conditioner in the dining area was not adequate to cool the entire building. Review of the job description for maintenance staff and Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 56 of 73 interviews indicate that Valleyhead School does not employ staff members to maintain the cleanliness of interior spaces of its facilities. Teaching, administrative staff and students are required to clean interior spaces, maintain supplies and remove trash. Observation confirms that spaces are not adequately clean and trash is not regularly removed. CRITERION NUMBER Legal Standard 13.9 Outdoor Space The school shall maintain or have access to an outdoor play area of at least seventyfive square feet per student using it at any one time. 18.04(7)(b) Outdoor play areas shall be accessible to direct sunlight and free from hazards and/or harsh or abrasive materials. If adjacent to a highway or other dangerous area, it shall be fenced with a non-climbable barrier at least five feet high. Rating: Implemented RESPONSE REQUIRED: No AREA 14: REQUIREMENTS FOR DAILY CARE CRITERION NUMBER Legal Standard 14.1 Clothing, Grooming and Hygiene The school shall make provisions with parents or, where appropriate, state agencies to assure that all students are provided with clean, appropriate and seasonal clothing as well as with personal grooming and hygiene articles and materials necessary to meet his/her individual needs. 18.03(5) Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 57 of 73 No CRITERION NUMBER Legal Standard The school’s staff shall understand the nutritional requirements of the students enrolled and provide an appropriate number of meals daily (three meals daily for residential programs), at reasonably appropriate times, which constitute a nutritionally adequate diet. 14.2 Food and Nutrition 18.03(7) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 14.3 Toileting Procedures and Individual Plans The private special education program shall develop and implement a written plan describing required procedures including regular toileting and diapering, disposal or laundering of soiled clothing or diapers and protecting the personal privacy of all students. Toilet training plans based on parental input, the IEP and the student’s physical and emotional abilities. 18.03(8) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead School does not have students enrolled who require toileting plans. Student record review and interviews indicate that a number of students have enuresis and encopresis, but no written plans have been developed for these students. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 58 of 73 AREA 15: PARENT AND STUDENT INVOLVEMENT CRITERION NUMBER Legal Standard 15.1 Parental Involvement and Parents’ Advisory Group The private special education program shall have a written plan for involving parents and shall have a Parents’ Advisory Group that shall advise the school on matters that pertain to the education, health and safety of the students in the program. The program shall designate a staff person to support the Parents’ Advisory Group. 18.05(4)(a) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that Valleyhead School has not developed a written plan for parent involvement or a parent advisory group. It has an Advisory Board that includes a parent as a member, but no parent advisory group. Interviews indicate that clinical staff at Valleyhead School work very diligently to identify a family member as a contact person for each student enrolled, especially for the many students who have parents who have terminated parental rights. CRITERION NUMBER Legal Standard 15.2 Orientation Procedures 28.09(11) The school shall develop and implement orientation procedures for parents and students upon student admission to the program. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 59 of 73 No CRITERION NUMBER Legal Standard When students have parents or guardians with limited English language skills, the private special education program ensures that general announcements and notices of extracurricular activities and other opportunities are distributed to them in the primary language of the home. 15.3 Information to be translated into Languages other than English Title VI; EEOA: 20 U.S.C. 1703(f); M.G.L. c. 76, s. 5; 603 CMR 26.02(2) Rating: Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that at this time Valleyhead Residential School does not have students enrolled or parents of students who have limited English language skills. Valleyhead submitted a written plan that does not include the name and job description of the staff person responsible for distribution of translated materials if this is required in the future. CRITERION NUMBER Legal Standard 15.4 Change of Student’s Legal Status 18.05(4)(b) The school shall have procedures for assuring that it is informed by a parent or guardian of any changes in a student’s legal status, and of the results of all judicial and administrative proceedings concerning the student. The school shall have written procedures for disseminating this information to appropriate personnel. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 60 of 73 No CRITERION NUMBER Legal Standard The program shall notify the placing school district when multiple efforts have been made, yet have failed to involve the parent and obtain necessary parental consent. 15.5 Parent Consent Matters requiring annual parental consent include, but are not limited to, the following: a. In coordination with responsible school districts, IEP-related matters b. Emergency medical care c. Medications d. Restraints e. Publicity, research, evaluation f. Field trips g. In coordination with responsible school districts, the Parental Notification Law pursuant to Chapter 71, Section 32A concerning curriculum that primarily involves human sexual education or human sexuality issues 28.07(1)(b) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation and student record review indicates that consent forms are signed and received at the time of admissions and not updated annually. A copy of the parental notification of curriculum concerning human sexual education or human was not submitted to the Department of Education or found in student records. CRITERION NUMBER Legal Standard 15.6 Student Involvement 34CFR 300.344 The program shall collaborate with the placing school district to ensure student participation in Team meetings where required by law and if appropriate. If the student does not attend the IEP meeting, steps are taken to ensure that the student’s preferences and interests are considered. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 61 of 73 Yes CRITERION NUMBER Legal Standard One year prior to the student’s reaching age eighteen, the program works collaboratively with the responsible school district to ensure consent is obtained from the student to continue the special education program upon turning age eighteen, or to ensure that another mechanism is in place to obtain consent, i.e.: The parent or other legally eligible party has petitioned and been appointed guardian by a court of competent jurisdiction The student chooses to share decision-making with his or her parent The student chooses to delegate continued decision-making to his or her parent or other willing adult 15.7 Consent at Age of Majority 28.07(5) (See also Criterion 15.3.) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 15.8 Registering Complaints 18.05(1)(b)16 Title IX: 20 U.S.C. 1681; 34 CFR 106.8; Section 504: 29 U.S.C. 794; 34 CFR 104.7; Title II: 42 U.S.C. 12132; 28 CFR 35.107; NCLB: Title X, Part C, Sec. 722(g)(1)(J)(ii) The private special education program shall develop and make available to parents and students a set of written procedures that may be used to register complaints regarding the student’s education and care at the school. The private special education program must also adopt and publish grievance procedures for students and for employees providing for prompt and equitable resolution of complaints alleging discrimination based on sex or disability. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead Residential School has developed three separate Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 62 of 73 complaint procedures for students, staff and parents. The complaint procedure for student only references discrimination. Interviews indicates that there is a complaint procedure in place for students to address other concerns about the program, but staff members were not able to articulate the details of procedures to review and address these concerns, including where this is documented and how issues are resolved. These student grievance procedures were not described in a written plan to the Department of Education. AREA 16: HEALTH AND MEDICAL SERVICES CRITERION NUMBER Legal Standard The school shall have a comprehensive, written health care policies and procedures manual that clearly describes provisions made for medical, nursing and infirmary care of students. This manual must be approved by a licensed physician, include all applicable policies and procedures, and be made available to staff. 16.1 Health care Policy and Procedure Manual 18.05(9)(d) 18.05(9)(c) Rating: Implemented RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 16.2 Physician Consultation The school shall secure the services of a licensed physician available for consultation. 18.05(9)(a) Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 63 of 73 No CRITERION NUMBER Legal Standard 16.3 Nursing The school shall secure the services of a registered nurse or a licensed practical nurse available as deemed necessary by the Department depending upon the health care needs of the school population. 18.05(9)(b) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review and interviews indicate that Valleyhead School’s plan for provision of nursing services is not sufficient to meet the needs of students enrolled. The school does not have a registered nurse on staff. Interviews indicate that nursing staff members do not have contact with the consulting registered nurse. CRITERION NUMBER Legal Standard 16.4 Emergency First Aid 18.05(9)(e) The school shall have written policies and procedures for emergency first aid and care including: a. Training of all direct service staff by a certified instructor in emergency first aid; b. Secure storage of adequate first aid supplies, including but not limited to bandages, body substance isolation gloves, gauze, adhesive tape, hydrogen peroxide or other cleaning solutions, and ipecac. c. Storage of and easy access to first aid supplies and health care policies and procedures in major activities areas; d. Posting of telephone numbers for the fire department, police station, poison prevention center, hospital emergency room and ambulance service serving the school in living quarters and educational facilities; e. Procedures to be followed in the case of illness or emergency such as motor vehicle accident, including methods of transportation and notification of parents; f. Procedures to be followed in the case of fire or other emergency; g. Procedures for informing parents of any medical care administered to their child or of any injury or illness that requires care other than basic first aid; and h. Procedures to be followed in the case of illness or emergency if parents cannot be reached. Rating: Partially Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 64 of 73 Yes Department of Education Findings: Review of the Health Care Manual indicates that all policies listed above do not contain details required, with the exception of the policies on training in emergency first aid and informing parents of their child’s injury or illness. Interviews indicate that staff members responsible for maintaining contents of first aid kits were not aware of locations where first aid kits can be found other than at the nurses station. CRITERION NUMBER Legal Standard 16.5 Administration of Medication 18.05(9)(f) The school has developed and implements written policies and procedures regarding the administration of medication including, but not limited to, the following: a. No medication is administered to a student without written authorization from a parent. Such authorization shall be renewed annually. b. No prescription medication shall be administered to a student without the written order of the physician prescribing the medication to that student. c. The school maintains written policies and procedures regarding prescription and administration of medication including authorization, prepackaging and staff training. d. Any change of medication or dosage must be authorized by a new order from a physician. e. A written record of the administration of prescribed medication to students shall be maintained. Such a record documents the side effects of medication and includes notification to attending physicians of changes in the student's behavior or health that may result from medication. f. All medicine shall be kept in a locked, secure cabinet and labeled with the student's name, the name of the drug and the directions for its administration. g. The school shall dispose of or return to the parents any unused medication. h. Medications must be delivered to the school by a responsible adult in a container labeled by the physician or pharmacist. i. Provisions must be made for refrigeration of medications, when necessary. j. The school shall have a written policy regarding the amount of medication to be kept on the premises at any one time for each student receiving medication. k. A review of medications administered to a student shall be incorporated into all progress reviews conducted for the student. Rating: Partially Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 65 of 73 Yes Department of Education Findings: Review of the Health Care Manual indicates that the private school’s policy on administration of medication indicates that it does not include the following: Written parental authorization for medication administration is updated annually Procedures regarding prescription and administration of medication including authorization and prepackaging Any change of medication or dosage must be authorized by a new order from a physician Written record of the administration of prescribed medication to students shall be maintained that documents the side effects of medication and includes notification to attending physicians of changes in the student's behavior or health that may result from medication Disposal of, or return to the parents, any unused medication Medicine shall labeled with the directions for its administration Medications must be delivered to the school by a responsible adult in a container labeled by the physician or pharmacist Review of medications shall be incorporated into all progress reviews of the student CRITERION NUMBER Legal Standard 16.6 Administration of Antipsychotic Medication 18.05(9)(f)(9) The school shall not administer or arrange for the administration of antipsychotic medication (drugs used in treating psychoses and alleviating psychotic states) except under the following circumstances: a. Antipsychotic medication shall be prescribed by a licensed physician for the diagnosis, treatment and care of the child and only after review of the student's medical record and actual observation of the student. b. The prescribing physician shall submit a written report to the school detailing the necessity for the medication, staff monitoring requirements, potential side effects that may or may not require medical attention and the next scheduled clinical meeting or series of meetings with the student. c. No antipsychotic prescription shall be administered for a period longer than is medically necessary and students on antipsychotic medication must be carefully monitored by a physician. d. Staff providing care to a student receiving antipsychotic medication shall be instructed regarding the nature of the medication, potential side effects that may or may not require medical attention and required monitoring or special precautions, if any. e. Except in an emergency, as defined in 18.05 (9)(g), the school shall neither administer nor arrange for the prescription and administration of antipsychotic medication unless informed written consent is obtained. If a student is in the custody of his/her parent(s), parental consent (in writing or in a witnessed conversation) is required. Parental consent may be revoked at any time unless subject to any court order. If the parent does not consent or is not available to give consent, the referral source shall be notified and judicial approval shall be sought. If a student is in the custody of a person other than the parent, a placement agency or an outof-state public or private agency, the referral source shall be notified and Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 66 of 73 CRITERION NUMBER Legal Standard f. g. judicial approval shall be sought. In an emergency situation, antipsychotic medication may be administered for treatment purposes without parental consent or prior judicial approval if an unforeseen combination of circumstances or the resulting state calls for immediate action and there is no less intrusive alternative to the medication. The treating physician must determine that medication is necessary to prevent the immediate substantial and irreversible deterioration of a serious mental illness. If the treating physician determines that medication should continue, informed consent or judicial approval must be obtained as required by 18.05(9)(e). The school shall inform a student twelve years of age and older, consistent with the student's capacity to understand, about the treatment, risks and potential side effects of such medication. The school shall specify and follow procedures if the student refuses to consent to administration of the medication. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Review of the Health Care Manual indicates that the private school’s policy on administration of antipsychotic medication does include details of the required elements above. This policy states that staff members are trained to monitor potential side effects of medications students are taking, but interviews indicate that Valleyhead has not implemented procedures that ensure the that side effects are efficiently and effectively monitored. CRITERION NUMBER Legal Standard 16.7 Preventive Health Care 18.05 (9)(f)(9)(h) The school shall develop and implement a written plan for the preventive health care of students that includes, but is not limited to the following: a. Provisions for each student to receive an annual comprehensive medical and dental examination; b. Vision, hearing, postural and other required screenings conducted in accordance with M.G.L. c. 71 s. 57; c. Provisions ensuring that all students are immunized as required by the Department of Public Health; d. Procedures for communicable disease notification and prevention of students and staff; e. A student or staff member who has a reported communicable disease shall be authorized by a physician to continue to be present within the school; the school shall notify all parents and referring agencies of the reported Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 67 of 73 CRITERION NUMBER Legal Standard f. g. h. i. communicable disease within the school. Provision of a locked, secure cabinet to keep all toxic substances, medications, sharp objects and matches out of the reach of students; Medications and medical supplies are not locked in the same cabinet as other toxic substances. Toxic substances are labeled with contents and antidote and the phone number for the nearest poison center is posted clearly. Provisions of family planning information, subject to any applicable state or federal legislation; and Procedures for protecting students from exposure to foods, chemicals, or other materials to which they are allergic. Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Review of the Health Care Manual indicates that at the time of admissions, students have a comprehensive medical and dental examination that includes vision, hearing, postural and other required screenings and immunizations, but it does not state that the private school will ensure that checkups are provided annually for enrolled students. Information on handling of toxic substances was also not found. CRITERION NUMBER Legal Standard 16.8 Receipt of Medical TreatmentReligious Beliefs In the absence of an emergency or epidemic of disease declared by the Department of Public Health, the school shall not require any student to receive medical treatment when the parents object thereto on the ground that such treatment conflicts with a religious belief. 18.05(9)(k) Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 68 of 73 No CRITERION NUMBER Legal Standard 16.9 Students with Comfort Care/Do Not Resuscitate Orders The private special education school program develops a policy on the care of a child with a DNR order. Special consideration must be given to meeting child and family needs as well as the students and staff. Rating: Reserved RESPONSE REQUIRED: No CRITERION NUMBER Legal Standard 16.10 Meningococc al Disease and Vaccination MGL, Chapter 76, s.15D 105 CMR 220.700 All new students at private residential schools that provide education to students in grades 9-12 must: Receive information about meningococcal disease and vaccine; and Provide documentation of receipt of one (1) dose of meningococcal vaccine within the last five years or qualify for one of the exemptions to immunization established by the statute. Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 69 of 73 No AREA 17: TRANSPORTATION SAFETY CRITERION NUMBER Legal Standard 17.1 Transportation Safety The program develops transportation procedures that ensure that vehicles are safe, insured, and operated by qualified and trained individuals, and that students are transported in a safe manner that is responsive to individual students’ needs and provisions of their IEPs. In the event of a motor vehicle accident, parents, school districts, human service agencies, and the Department of Education are notified immediately. The school ensures that any person who is responsible for operating a vehicle owned or contracted for by the school which carries students shall receive in-service training on overall transportation safety and the individual needs of the students they transport. 28.09(11)(b) Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Documentation review indicates that Valleyhead Residential School does not have detailed procedures for staff members to follow when transporting students. AREA 18: STUDENT RECORDS CRITERION NUMBER Legal Standard 18.1 Student Records Approved special education schools shall keep current and complete files for each publicly funded enrolled Massachusetts student and shall maintain such files consistent with the Massachusetts Student Record Regulations (603 CMR 23.00) and MGL c. 71, s.34H. 28.09(10) Rating: Implemented RESPONSE REQUIRED: Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 70 of 73 No CRITERION NUMBER Legal Standard 18.2 Student Records (Log of access and face sheet information) 28.09(10) Student records shall be legibly dated and signed by persons making entries. Individual access logs shall be maintained for each record. All records must contain: a. Log of access consistent with requirements of the Massachusetts Student Record Regulations b. Face sheets updated at least annually with the following information: o Name o Date of birth o Recent picture o Date of admission to private school o Name of educational case manager assigned by the public/ private school program o Location of residential service within facility (if applicable), and name of residential case manager or supervisor o Date initially eligible for special education (if known) o Date of most recent special education evaluation(s) o Date of next expected 3-year reevaluation o Starting and expiration dates of current (or most recent) IEP o Primary language of student o Legal status of student o If under 18: in custody of both parents, one parent [specify], legal guardian [specify], other [specify] o If 18 or over: makes own decisions; under legal guardianship [specify]; has shared role with parent in education decisions [specify] o Other state agency/ies involved with student o Parent/guardian contact information: names, addresses, home & work telephone numbers, e-mails o Primary language of parents/guardian o Contact information of persons other than parents to be contacted in an emergency (names, addresses, telephone numbers) o Educational surrogate contact information (if applicable) o Notation of allergies and/or any other medical condition affecting student’s well-being (e.g., seizures) o Information specific to the student regarding the handling of medical emergencies c. Copy of current IEP d. Copies of quarterly progress reports and any modification of the IEP e. Copy of the student's termination or discharge plan f. Health records, including reports, documentation of physical examinations, allergies, screening tests, results of medical care g. All evaluations or assessments conducted of the student h. Pertinent correspondence concerning the student i. Information regarding the use of behavior management interventions Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 71 of 73 CRITERION NUMBER Legal Standard j. including, but not limited to, restraint (chemical, mechanical, physical) and time-out procedures Copies of all incident reports Rating: Partially Implemented RESPONSE REQUIRED: Yes Department of Education Findings: Student record review indicated that Valleyhead Residential School has developed a comprehensive Face Sheet that contains all elements required by the Department of Education and more to present information on a student for all staff members in a location that is easily accessible to all staff members. Many student records did not contain a copy of the Transition Planning Chart and progress reports as often as required in the school’s policy. Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 72 of 73 PRIVATE SCHOOL PROGRAM REVIEW REPORT 2007.doc File Name: Valleyhead Intensive Care Program Final Report 2007 Last Revised on: December 21, 2007 Prepared by: SKH, BH Massachusetts Department of Education – Program Quality Assurance Services Valleyhead Intensive Care Program Review Report – December 21, 2007 Page 73 of 73